Business Encounter Data Analyst

It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary:

The Business Encounter Data Analyst is responsible for compiling and analyzing encounter data and understanding the claim impact of changes and decision to the business process to ensure that CMS and State Service Level Agreements (SLAs) are achieved. This individual will support the encounter data lifecycle process working closely with business and technical resources as well as document and illustrate business requirements, processes, and deficiencies across the organization, our vendors, and our regulators.

Our Investment in You:

·       Full-time remote work

·       Competitive salaries

·       Excellent benefits

Key Functions/Responsibilities:

• Understand the claims encounter data requirements in detail to ensure claims data is complete, accurate, and timely.
• Responsible for reviewing encounter rejections and providing resolution of minor to complex data/system issues or processes.
• Responsible for the development and maintenance of supporting business processes and workflows.
• Recognize inconsistencies and gaps to improve productivity, accuracy and data usability and streamlining procedures and policies.
• Provide critical analysis of functional performance, and make recommendations for enhancements, and process improvements.
• Build, sustain and leverage relationships to constantly allow for continuous improvement of the encounter data business process.
• Provide encounter data support to vendors and ensure understanding of regulatory encounter requirements.
• Participate in claims encounter initiatives such as working with IT and other internal departments to automate claims encounters functions.
• Understanding of how claims payment methodologies, adjudication processing and CMS and State encounter regulations interrelate to maintain compliant encounter reconciliation processes and SLA’s.
• Stay current with the needs and operations of the regulatory deliverables.
• Interacts with business stakeholders, internal and external as appropriate, to understand new business requirements and enhancement requests.
• Provide business encounter subject matter expertise for internal departments and both CMS and State agencies.
• Performance for timely and accurate reviews must meet or exceed internal, CMS, and State SLA requirements.
• Other duties as assigned.

Supervision Exercised:

·       None

Supervision Received:

·       Indirect supervision is received weekly

Qualifications:

Education Required:

• Bachelor's Degree in a related field or the equivalent combination of training and experience 

Education Preferred:

·       AHIMA or other nationally recognized Coding/Billing Certification.

Experience Required:

·       5 or more years experience in a fast paced, managed healthcare environment.

·       5 or more years experience with encounter data operations, claims processing, and/or provider billing.

·       3 or more years of claim coding and billing processes, including CPT, ICD-10 and HCPCS coding.

·       Advanced knowledge of HIPAA transaction regulations and 837 EDI standards.

·       Experience working with Medicaid, Medicare or commercial encounter, coding and/or regulatory guidelines.

Experience Preferred/Desirable:

·       Edifecs encounter data software.

·       Cognizant Facets claim adjudication system.

·       Experience with industry standard payment rules and methods.

Required Licensure, Certification or Conditions of Employment:

·       Successful completion of pre-employment background check

Competencies, Skills, and Attributes:

• Effective collaborative and proven process improvement skills.
• Good communication skills, both oral and written, ability to interact well with others at all levels, strong organizational skills, strong customer service skills and orientation.
• A strong working knowledge of Microsoft Office products.
• Independent thinker and problem solver with an analytical mind and the ability to solve complex data and workflow issues.
• Detail oriented.
• Time management skills; capable of multi-tasking and prioritizing work.

Working Conditions and Physical Effort:

• Regular and reliable attendance is an essential function of the position.
• Work is normally performed in a typical interior/office work environment.
• No or very limited physical effort required. No or very limited exposure to physical risk.

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances.